The supply of rapid diagnostic tests (RDTs) and artemisinin-based combination therapy (ACT) medicines needs to be synchronised to prevent high levels of ACT misuse in Nigeria, a new study has found. Malaria Consortium researchers supported Nigeria's National Malaria Elimination Programme (NMEP) to investigate the availability of RDTs and ACTs in Nigeria under special private sector subsidy schemes which aimed to address financial barriers to the accessibility of malaria treatment. A key finding was that to avoid the misuse of anti-malarials, correct diagnosis of fever prior to drug prescription is essential. The findings were published in Malaria Journal in February and June.
Malaria is one of the leading causes of death in Nigeria. According to the 2020 World Malaria Report, the country accounts for 27 percent of malaria cases globally and 23 percent of deaths from the disease. Malaria Consortium has been working with the Ministry of Health and other stakeholders since 2008 to reduce the burden of malaria in Nigeria. This research is part of the organisation's ongoing work to support the NMEP to increase available data on malaria and related contributing factors to health outcomes so as to make more evidence available for decision-making.
The subsidy schemes at the focus of this research, Affordable Medicines Facility - malaria (AMFm) and the Private Sector Co-payment Mechanism (PSCM), were in place in Nigeria between 2010 and 2017. The schemes subsidised the cost of quality-assured artemisinin-based combination therapy (QA-ACT), the recommended first line antimalarial medicine for uncomplicated malaria, in the private sector. Nigeria was among a number of selected countries that implemented AMFm and PSCM programmes, which subsidised ACTs but not RDTs, even though both the diagnosis and treatment of malaria are integral parts of malaria case management.
In 2018, following the end of the PSCM, Malaria Consortium and researchers conducted a two-part market survey to assess how the curtailment of the subsidy scheme impacted the malaria case management commodities market. The research consisted of an outlet survey targeting private pharmacies and Proprietary and Patent Medicine Vendors (PPMVs) across different regions of Nigeria to assess supply-side market factors related to availability of RDTs and a household survey carried out to determine demand-side factors related to knowledge of RDTs, healthcare-seeking practices and affordability.
The private, for-profit healthcare sector plays a significant role in malaria case management in Nigeria but can be difficult to regulate and monitor. Malaria Consortium has worked , there are often concerns about whether consumers have access to appropriate, high quality, and affordable treatments and diagnostics in line with current recommendations.
The researchers found that at the time of the survey the availability of diagnostic RDTs, was low in both outlet types (< 20 percent availability) and was significantly lower in PPMVs compared to pharmacies. Reasons for not restocking RDTs included low demand and no supply.
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The low availability of RDTs sits in stark contrast to the high availability of ACT medicines, the researchers discovered. Availability of artemisinin-based combinations increased significantly over the PSCM period and was almost universal, at more than 99 percent, by the time of the 2018 market survey.
Maxwell Kolawole, West and Central Africa Programmes Director at Malaria Consortium and co-author of the research said:
"It's clear that the deficit in RDT availability must be urgently addressed. The decision whether to diagnose was, for most households, based on whether they could access RDTs, alongside their own personal experience of malaria. This means the low availability of RDTs and high availability of ACT medicines present a real risk for the misuse and overuse of anti-malarials. We know that such misuse can lead to poor treatment outcomes and adds to drug resistance pressure on the parasite, potentially hindering malaria elimination from the country",
Most surveyed households diagnosed malaria based on experience, while one third said it would visit a PPMV or pharmacy. Half of the households had heard of RDTs (48.4 percent) and 38.6 percent thought they were affordable.
The research concluded that the subsidy scheme appears to have had a significant impact on improving availability and affordability of ACT and this is twinned with high consumer demand for malaria treatment from private outlets, particularly among PPMVs. Malaria Consortium believes that a subsidy for RDTs currently in the market should be explored as it could make the positive impact of subsidies on the ACT market more sustainable and improve the quality of malaria case management in general.
